NCLEX - Test one

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.

360 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml

A client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation in the anteroseptal leads and T-wave inversion in leads V3 to V5. Which medication should the nurse prepare to administer?

Nitroglycerin The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to order an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs, which may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or asystole, a physician may order epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects.

The nurse is assessing an older adult's skin. The assessment will involve inspecting the color, pigmentation, and vascularity. What should the nurse assess?

Changes from the normal expected findings Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.

The nurse is caring for a client who has a order for 1000 mL of IV fluid every 8 hours. When the nurse's shift began at 8 pm, there was 500 mL remaining in the IV fluid bag. How many mL would the nurse expect to be in the bag at midnight?

0 Because each 1000-mL bag infuses over 8 hours, Infusion rate = 1000 mL/8 hr = 125 mL/hr. There are 4 hours between the start of the shift and midnight. Therefore, the amount of fluid that will infuse by midnight is Amount = 125 mL/hr x 4 hr = 500 mL. Because only 500 mL remains in the bag at the start of the shift, the IV bag will be empty at midnight. The nurse would hang another bag for the client.

A client is ordered to receive 1,000 mL of 0.45% normal saline with 20 mEq of potassium chloride (KCl) over 6 hours. The infusion set administers 15 gtt/ml. How many drops per minute should this client receive? Record your answer using a whole number.

42 The flow rate is determined by the rate of infusion and the number of drops per milliliter of the fluid being administered. gtt/ml x amount to be infused/number of minutes = the I.V. flow rate 15 gtt/ml x 1,000 ml/360 min = 42 gtt/min

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should assign the infant to which room?

A private room To reduce the risk of infection transmission, an infant with diarrhea of undetermined origin should be placed in a private room until a causative organism can be identified. However a negative pressure room is not needed because airborne precautions are not required with diarrheal disease.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?

An exercise routine that includes range-of-motion (ROM) exercises Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?

Client with a compromised skin graft A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy is not used to improve the oxygenation status of a client with chronic obstructive pulmonary disease or pneumonia. This type of treatment would not encourage bone healing after a fracture.

The nurse would question the prescription for a fetal scalp electrode on which client?

Client with an HIV infection Placement of a fetal scalp electrode should be avoided when a client has HIV because it increases the risk of transmission to the fetus. The use of a fetal scalp electrode is indicated when precise tracing are needed to monitor changes associated with fetal hypoxia and satisfactory tracing cannot be obtained with external methods. The presence of decelerations, meconium stained fluid, and prolonged second stage of labor may all be indications for placing a fetal scalp electrode.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea and chest discomfort. What should the nurse do first?

Elevate the head of the bed 30 to 45 degrees Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The HCP must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

In the first stage of labor, a client with a full-term pregnancy has external electronic fetal monitoring in place. Which fetal heart rate pattern suggests adequate uteroplacental-fetal perfusion?

Fetal heart rate accelerations Fetal heart rate accelerations of at least 15 beats/minute for at least 15 seconds suggest adequate uteroplacental-fetal perfusion. Persistent fetal bradycardia may indicate hypoxia, arrhythmia, or umbilical cord compression. Variable decelerations also suggest umbilical cord compression. Late decelerations may reflect decreased blood flow and oxygen to the intervillous spaces during contractions.

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion?

Fetal heart rate variability within 5 to 10 beats/minute Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered normal. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — an abnormal pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation.

A nurse is reviewing the medication administration record and is getting ready to administer the flu vaccine. Prior to administering the vaccine, the client's spouse asks about getting the vaccine. Which locations will administer the flu vaccine to a client who does not have a primary care provider?

Health department Pharmacy Urgent care clinic Flu vaccines are offered in many locations, including doctor's offices, clinics, health departments, pharmacies, and college health centers, as well as by many employers, and even in some schools. Vaccines would not typically be available in a fitness center.

Which condition should the nurse expect to find in a client diagnosed with hyperparathyroidism?

Hypercalcemia Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hyperphosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.

A client is admitted with an eating disorder. Which client response should the nurse address first?

I feel dizzy and light-headed when I get up The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

Which statement indicates that the client understands the home care of a colostomy?

I should be able to establish a regular pattern of elimination with my colostomy. Many colostomies, especially those located in the descending colon, can be regulated to evacuate on a schedule.All ostomy appliances should be applied using a peristomal skin barrier.There should be no pain associated with touching the stoma.After the immediate postoperative period, it is not normal for blood to be present in the stool. Bleeding should be reported to the client's health care provider.

A client undergoing chemotherapy tells the nurse, "I don't want to get out of bed in the morning because I'm so tired." What information should the nurse include in the care plan?

Individually tailored exercise program An individualized exercise program will increase stamina and endurance. Weight lifting may be too vigorous. Filgrastim is used to increase white blood cells and is not applicable in this situation. Decreased hemoglobin and hematocrit predisposes the client to fatigue due to decreased oxygen availability. Bed rest causes muscle atrophy, adding to fatigue, and can contribute to deep vein thrombosis (DVT).

A nurse's coworker tells the nurse, "I am not going to get this year's flu vaccination. Last year I felt sick right after I got it." What is the nurse's best response?

Reducing your own risk of getting influenza ultimately benefits your clients Framing the issue in terms of benefiting clients is likely more effective than making a declaration about professional responsibility. Influenza vaccinations do not confer 100% protection against the disease.

A client attends a follow-up visit to a clinic after being diagnosed with atypical depression. The practitioner prescribed tranylcypromine sulfate, 10 mg by mouth twice a day during the last visit 14 days ago. Which would be the priority action by the nurse for this client?

Screen the client for new, worsened, or increased depression Clients taking this medication could have increased suicidal thoughts and actions and should be screened for new, worsened, or increased depression. Although it is important to ask about over-the-counter medications, which could interact with tranylcypromine sulfate, this would not be the priority assessment. Clients on tranylcypromine sulfate do have an increased sunburn risk, but this would not be a priority to teach. The client's blood pressure should be closely monitored but not the heart rate.

Upon the child's return from the post-anesthesia recovery unit (PACU) after a tonsillectomy, the nurse should place the child in which position?

Side lying Placing the child in a side-lying position facilitates drainage of secretions and helps prevent aspiration.The Trendelenburg position is contraindicated because it decreases effective lung volumes.The supine position is contraindicated because of the increased risk of aspiration.The lithotomy position is used for a pelvic examination.

A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement?

Teaching how to express the breasts Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.

A 10-year-old child is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as prescribed. The child's left leg is immobilized in a splint. What is an appropriate goal at this time for this child?

The child will change position every 2 hours while awake To prevent pressure injuries, the child must turn and change positions every 2 hours while awake. However, during the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. Therefore, the nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate goal because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities is not a realistic goal, because an acutely ill child is not likely to be interested in activities; this goal would be suitable after the acute disease phase ends.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag?

Triage priority Identifying information when possible (such as name and age) Medications and treatments administered Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.

A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which instructions would be appropriate?

Use ice packs for 20 minutes every 3 to 4 hours Ice packs cause vasoconstriction and can provide temporary relief of breast engorgement for the bottle-feeding mother.Breast engorgement is transitory and usually disappears within a few days. A tight breast binder is not recommended because it can worsen the engorgement and restrict blood flow. A supportive bra should be worn at all times by both bottle-feeding and breastfeeding mothers.Taking a warm shower may help relieve some of the discomfort of the breast engorgement.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6" (15 cm) while both legs support the client's weight To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

A charge nurse is completing client assignments for the nursing staff on the pediatric unit. Which client would the nurse refrain from assigning to a pregnant staff member?

an 8-year0old with rubella Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Ringworm is caused by a fungal infection on the skin. Standard hand hygiene is necessary. Kawasaki's disease is an autoimmune disease in which blood vessels become inflamed. Roseola is a virus transferred by oral secretions.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn?

increased amounts of vernix Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between the estimated date of conception and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28-30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation, although it is associated with other conditions, including prematurity and small size for gestational age.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? Nurses:

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

A client recovering from an acute myocardial infarction makes a joke about the client's sexual function to the nurse during morning care. What action should the nurse take?

Ask the client if there are questions related to sexuality the client would like to discuss Clients are often concerned about resuming sexual activity after an acute myocardial infarction but are embarrassed to ask directly about the topic. The joke about the client's sexual function could be an effort to open a dialogue. The nurse has a responsibility to respond compassionately and professionally, a duty that excludes ignoring the comments or making light of them. Given the context—a single comment (not a pattern of comments) after an acute myocardial infarction—there is not enough information to conclude that the joke constitutes harassment. Opening a dialogue to understand the client's motivation is the priority.

A 3-year-old boy has arrived in the emergency department. The nurse documents the following assessment findings in the client's chart, knowing that they are consistent with which disease process?

Pneumonia The elevated fever, shallow respirations, decreased breath sounds, rales, harsh cough, and productive mucus are findings associated with pneumonia. Typically, there is no fever with asthma and cystic fibrosis, and bronchiolitis presents with a low-grade fever. Wheezing is associated with asthma and bronchiolitis; however, this was not found upon physical examination of this client. Bronchiolitis produces a dry cough, and pneumonia causes a productive, harsh cough. The client with cystic fibrosis typically presents with wheezing, rhonchi, and thick, tenacious mucus.

The family of a client who is unconscious following a stroke tells the nurse they feel "pressured" by the resident physician to insert a feeding tube. They are reluctant to agree to the procedure because they believe this action is not something the client would want. Which response by the nurse illustrates ethical practice?

"I can arrange for you to talk with the health care team about your loved one's situation." The nurse demonstrates ethical behavior when offering to find resources, answer questions, and provide support to the client's family. Unethical behavior would include providing inaccurate information, giving advice, discussing personal information, or implying that the medical resident is not competent.

A nurse is caring for a client receiving thioridazine 300 mg TID. It would be most important for the nurse to follow up with which client statement?

My eye doctor said I have a new pigmented layer on my retina Retinal pigmentation may occur if thioridazine dosage exceeds 600 mg per day; this can lead to vision loss, so the nurse should follow up on this statement. Drinking ten glasses of water a day is encouraged. Weight gain is an adverse reaction to thioridazine and should be followed up; however, the immediate priority is preventing vision loss. Administration of thioridazine can be given without regard to food. Therefore, taking the first dose immediately in the morning is appropriate.

The nurse is teaching a client newly diagnoses with a peanut allergy about how manage the allergy. What information should be included in the teaching?

Wear a medical alert bracelet List symptoms of peanut allergy Identify ways to manage allergy while dining out Carry EpiPen autoinjector at all times Wearing a medic alert bracelet allows others to be alerted of the allergy. Listing symptoms of the allergy makes the client aware of the allergic reaction if symptoms are being experienced. Identifying ways to manage allergies while dining out allows the client to be safe from a potential reaction. All food labels should be read not only baked items. The EpiPen autoinjector should be carried at all times in case it needs to be administered because of an allergic reaction.

The nurse should assess a client at risk for acute disseminated intravascular coagulation (DIC) for which early sign?

Bleeding without history or cause There is no well-defined sequence for acute DIC other than that the client starts bleeding without a history or cause and does not stop bleeding. Later signs may include severe shortness of breath, hypotension, pallor, petechiae, hematoma, orthopnea, hematuria, vision changes, and joint pain.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.

A new mother states. "My baby spits up after every feeding." Which interventions should the nurse teach to his mother first?

Burp the infant more frequently during each feeding Frequent burping decreases the amount of air the infant has in the stomach and should be the first intervention. Feeding smaller portions more frequently may help if the infant is taking large amounts. Infants should be fed every 2 to 4 hours. Elevating the head of the bed 30° may help if the cause is gastroesophageal reflux. Formula may have to be changed if it is determined that the spitting is related to milk intolerance.

The client with benign prostatic hypertrophy is being transferred from the emergency department to a surgery unit. Which information should be included in the report from the nurse in the emergency department to the nurse responsible for admitting the client?

"The client was catheterized, and 1,000 mL of urine was obtained. The urine appeared cloudy, and add a specimen was sent to the laboratory." A report about the client's condition should be as clear, pertinent, and concise as possible. It should be free of subjective information that could be interpreted differently by different caregivers. The report mentioning that a specimen was sent to the laboratory does not indicate how much urine had been drained from the client's bladder and how the urine appeared. The report describing the client as cooperative is subjective and provides only limited client data. The report that mentions that the client was in the emergency department for 3 hours does not mention the treatment provided.